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.^mith, Fre-dcYieK Charley 



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NOU 23 IS 1 



L161— H41 



UNITED STATES PUBLIC HEALTH SERVICE 

TUBERCULOSIS 

ITS PREDISPOSING CAUSES 



BY 



F. C. SMITH 

Passed Assistant Surgeon 
United States Public Health Service 



SUPPLEMENT No. 3 

TO THE 

PUBLIC HEALTH REPORTS 

February 7, 1913 




WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1913 









c< 



TUBERCULOSIS. 

ITS PREDISPOSING CAUSES. 

By F. C. Smith, Passed Assistant Surgeon, United States Public Health Service. 

The public is already fairly well instructed concerning the exciting 
cause of tuberculosis, i. e., the tubercle bacillus. It is common 
knowledge that sputum containing this germ is the chief means of 
spreading infection. Spray from* a coughing consumptive, dust, 
flies, doorknobs, drinking cups, and towels are common means of 
spreading infection. There are constantly over 1,000,000 people in 
the United States sick with tuberculosis, many of whom are careless 
or ignorant. There are also other sources of infection. As a result 
the tubercle bacillus is everywhere, and in spite of all precautions 
the ordinary individual at an early age is already slightly infected 
with tubercle bacilli. 

INFECTION PRACTICALLY UNIVERSAL BY THE SIXTEENTH YEAR. 

If a drop of tuberculin is rubbed into the abraded skin of a very 
young child no reaction follows. If the drop of tuberculin be rubbed 
into the skin of a person who is or has been infected with tubercu- 
losis a reaction follows in a few hours, manifested by a small area of 
redness, which disappears after a few days and is unattended by any 
harmful effects. This is the cutaneous tuberculin test of Von 
Pirquet. 
It was soon found that hundreds of people reacted to the tuberculin 
^,test who had no sign of tuberculosis. About 90 per cent of white 
children between the ages of 12 and 13 and practically all adults 
* will give positive reactions, but the children of different communi- 
| ties give slightly different results. The Indians of Taos, N. Mex., 
J an isolated community, were found during the recent investigation of 
disease among the Indians by the United States Public Health Serv- 
ice to be almost free from tuberculosis, and only 3 of the 64 school 
children tested there showed positive reactions. Of 1,145 other 
Indian school children tested, however, 779 reacted positively. We 
must conclude that the communitjr free from almost universal in- 
fection is rare. The examination of large numbers of bodies dead 

(3) 

77411°— 13 



from other causes than tuberculosis in various parts of the world has 
shown, at the hands of numerous investigators, that a small area of 
healed or latent tuberculosis can almost always be found in the adult. 

TUBERCLE BACILLI HARMLESS UNDER CERTAIN CONDITIONS. 

Most of the children who react to the tuberculin test are not only 
apparently healthy but never break down from tuberculosis, although 
they have been the recipients of a large or small dose of living tubercle 
bacilli. Practically all adults are infected to some degree with 
tubercle bacilli and though many develop tuberculosis, especially 
during their years of greatest stress, the majority successfully resist 
it. It will at once occur to the reader that infection is perhaps a 
matter of dosage, that a large number of virulent bacilli inhaled or 
ingested may cause tuberculosis in an individual, whereas a small 
dose will be rendered innocuous by a high degree of resistance from 
a virile body. This is undoubtedly true. There is even a certain 
measure of protection derived from a small dose of tubercle bacilli 
well resisted. 

These latent germs of infection, the potential factors of tubercu- 
losis, in themselves probably give a certain degree of immunity 
against the effects of larger doses which one may later unfortunately 
experience. The individual is in a small degree vaccinated against 
tuberculosis. Too much comfort must not be derived from this, 
however, as in young children infection of any degree is apt to be- 
come generalized and rapidly fatal, and large dosage due to repeated 
exposures will cause even an adult to succumb. Hence no sanitary 
precaution should be neglected at any age to reduce the frequency and 
extent of exposure to tubercle bacilli. It must be remembered also 
that these bacilli of latent infection are nevertheless living bacilli 
capable of remaining virulent in the living body for many years and 
that the apparently healthy host may lose his immunity to them in 
several ways, many of which are not well understood. The most 
common ways of losing immunity and the ones most easily prevented 
are those discussed in this paper — the predisposing causes of 
tuberculosis. 

WEAKENED RESISTANCE OR PREDISPOSITION. 

In very early times it was observed that tuberculosis is more apt 
to occur at certain ages and under certain conditions of life. Hippoc- 
rates, the father of medicine, noted that it was most frequent between 
the ages of 18 and 35, a period which calls for the greatest physical 
and mental efforts. Dr. Bonney mentions " the old English idea that 
consumption was the cause of death of nearly all hard zealots in the 
field of letters, law, love, medicine, and religion." It is common 
knowledge now among physicians that any cause which weakens the 



individual, lessens his resistance and predisposes to tuberculosis. A 
powerful physique is no safeguard. Bridge says : " Physically strong 
people will not resist tuberculosis better than less muscular subjects. 
Athletes acquire it rather more readily than thin, weakly people with 
spare musculature but normal organic vigor." Baldwin states: 
"Adults of good physique, in functional and organic health, possess a 
nearly perfect protection against natural infection by tubercle 
bacilli," but adds, "Any weak moment * * * may play the part 
of a predisposition." To maintain normal vigor and functional 
health requires the observance of a multitude of details and a con- 
sideration of the chief causes of lowered vitality. 

LACK OF PROPER FOOD. 

The well fed resist tuberculosis well, the underfed yield readily. 
Clinical observations have abundantly proved this fact in both man 
and animals. Actual want is by no means the commonest cause of 
poor nourishment although it must be reckoned with, especially in 
our great cities, such as New York, where it is said many hundred 
school children go breakfastless to school. In the average American 
household too little time is given to the study of children's diet dur- 
ing the first decade of life and even when food is properly prepared 
for them it must not be forgotten that it often takes time and patience 
to induce a playful and capricious child to eat the proper things in 
sufficient quantities. Every attack of indigestion, every missed or 
partially consumed meal has its adverse effect on nutrition at any 
age of life. Many people are underfed who consider themselves 
well fed. The rich business man who hastily consumes a scanty 
breakfast of toast and coffee and works hard all day in an office with 
only a hasty lunch at noon, can not consider himself well fed even 
though he consumes a full meal in the evening and has a late lunch 
after the theater. His child who refuses at table wholesome ar- 
ticles of food, such as bread and butter, vegetables and meat, can not 
maintain a satisfactory degree of nourishment. Candy and cookies 
taken between meals, and frequently accountable for the lack of appe- 
tite at table, can not possibly be considered a satisfactory substitute 
for proper food. 

A lack of knowledge of food values is very common, especially in 
cities where delicatessen products made to tempt the eye and palate 
too often in the busy urban life take precedence over wholesome 
soups, roasts, and stews from the home kitchen. It should not be 
forgotten that fatty articles of food, including butter, fat meats, 
and olive oil are especially valuable in building up resistance to 
tuberculosis, but the diet must be suited to* the age of the individual. 
Bread and butter, meat, and abundant vegetables must not be slighted 
simply because milk and eggs are so commonly mentioned in this 
connection as ideal foods. 



EXHAUSTION. 

Next to lack of food, great fatigue is the greatest predisposing 
factor in tuberculosis. Exhaustion may be produced by long hours 
of heavy work and also by lack of sleep, by worry, long hours of 
study and any excessive or prolonged exertion, either work or play. 
Dancing in itself is harmless, but if it comes at the end of a day's 
work and is indulged in until late hours its effects upon general health 
will be deleterious. Even outdoor sports, which are certainly to be 
encouraged, may defeat their chief end if indulged in immoderately 
or to the exclusion of proper resting periods. Child labor, either in 
factory or at home, excessively long working hours, occupations 
which can not be interrupted for Sunday rest or which tempt or 
drive to excessive effort or " speeding up," all tend to weaken resist- 
ance and predispose to tuberculosis. 

BAD AIR. 

The air of poorly ventilated rooms is bad. Not only in factory and 
workshop and in overheated, poorly ventilated places of amusement, 
but in his own home, the ordinary individual frequently lacks good 
air. When air is breathed and rebreathed it becomes laden with 
poisonous matters. A person fresh from the pure outdoor air will 
feel oppressed upon entering such an atmosphere and will notice a 
bad odor in the room. When he goes forth he will carry the taint 
of such a place in his garments. One who lives long in vitiated air 
grows pale, loses appetite, takes cold easily, and becomes tired upon 
slight exertion. If several people occupy the room, or if gas or oil 
is burned in it, the contained air rapidly becomes highly polluted 
unless it is frequently renewed. The effect of bad air and lack of 
sunshine on infected rabbits has been studied by Dr. Trudeau, who 
found that animals confined in a cellar died of tuberculosis, while 
similarly infected ones recovered in the open air. Remembering that 
many babies, most children, and all adults are infected with tubercle 
bacilli, and knowing the fatal effects of close confinement, the need 
of good ventilation becomes imperative. 

Air flows very much as water does; to renew itself in a room it 
should have an inlet and an outlet, A bucket of dirty water half 
imersed in a flowing crystal stream remains dirty. A small trickle 
of clear water will not cleanse a pond constantly receiving pollution 
from another source. A room must be well flushed with flowing air 
to sweep out pollution, and the flow should be constant both in 
summer and winter. Ventilation at night is most important, the 
fear of night air being without any foundation. With sufficient bed- 
clothes there can be no excuse for leaving even partially closed a 
single window in the room. 



OTHER DISEASES. 

It has long been known that measles and whooping cough in chil- 
dren are especially liable to be followed by tuberculosis of the lungs, 
and every effort should be made to protect a child from these dis- 
eases. Mouth breathing should be corrected and adenoids removed. 
Scarlet fever, influenza and colds, typhoid fever, and all diseases 
which lower resistence, lessen nourishment, and increase the stress of 
life at any age must be reckoned with as important factors in pre- 
disposing to tuberculosis. 

ALCOHOL AND TOBACCO. 

There was a time when whisky was considered good for the tuber- 
culous patient, and there have been some who believed in the anti- 
septic powers of smoke. It is now known and taught that neither of 
these agents has any place in the prophylaxis or treatment of this 
disease. The inhaled smoke of cigarettes is especially harmful to the 
delicate air passages as well as weakening in its effects on the system. 
Alcohol in immoderate quantities impairs digestion, encourages 
irregular habits, and seems to especially predispose the subject to 
pulmonary disease. 

SUMMARY. 

At an early age practically all people have become slightly infected 
with living tubercle bacilli. This fact need not cause alarm, because 
it probably gives a slight degree of protection against subsequent 
infection. Safety, however, depends on the maintenance of a high 
degree of organic resistance to prevent these latent bacilli from pro- 
ducing active tuberculosis. This is not to be accomplished by becom- 
ing an athlete but by the daily observance of general hygienic princi- 
ples throughout life. Keep the body well nourished; avoid great 
fatigue; work and sleep in well-ventilated rooms, in freely flowing 
air, and spend as much time as possible outdoors, but carefully reserve 
hours for adequate rest as well as for recreation ; practice deep breath- 
ing and proper carriage ; avoid other diseases as far as possible ; and 
be temperate in all things. 

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